Parent/Caregiver Declaration

Approved Referrer

Referrer Name *

Organisation *

Position *

Address *

Ph: Work *

Ph: Home *

Mobile

Sports Club ( name of the club you wish to join) *

Season Start Date *

Application Details

To be completed by the referrer and should include how the applicant meets the grant criteria, how the referrer knows the applicant, why the applicant wishes to join a club and any other supporting information.

Details *

Grant Amount

Item Requested ( membership, equipment) *

Amount Requested - Please list individual item and amount *

Approved Referrer Declaration

I have read and understood the grant conditions and understand that I am making this application on behalf of the named applicant. I also declare that to the best of my knowledge, the applicant meets all of the grant criteria and that I am responsible for communicating with the applicant in regards to this grant and ensuring that the grant conditions are met.